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Registration form for the recognition process for Dementia Friendly Communities in Northern Ireland

Registration form for the recognition process for Dementia Friendly Communities in Northern Ireland

Recognition process for dementia friendly communities

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1. Please tell us the name of the person filling out this form. * Required

2. Please provide your email address * Required

3. Please tell us the name of the person who is taking responsibility for meeting the requirements of the recognition process if different to above.

4. Please provide their email address if different to above

5. Please tell us where the community becoming dementia friendly is? * RequiredHelp: You can give the name of the village/town/city, region and county for example.

6. Is the area becoming dementia friendly best described as one community (such as one town or one area) or an initiative that is spread across areas? * Required

One community Spread across areas Other

7. Please give more details if you answered 'other' to the previous question

8. Is this community best described as predominantly rural, village, town, city or mixed? * Required

Rural Village Town City Mixed

9. Please give the approximate size of the population for the community becoming dementia friendly * Required

10. Does your community have a local dementia action alliance? * Required

Yes No Is in development

Help: If you are not sure please check on the Dementia Action Alliance website, http://www.dementiaactionalliance.org.uk

11. Is your community already in the process of becoming a dementia friendly community? * Required

Yes No

12. If you answered yes to the previous question can you briefly describe the key activities that you have under taken

13. Communities will be required to have publicly available information on their actions to become dementia friendly. Please tell us where you intend to hold this information, for example on the local dementia action alliance site or on a page of another website? * Required

14. Please tell us how you are intending to engage with people with dementia living in your community in your plans to become dementia friendly? * Required

15. Please tell us how you are intending to use the 'working towards becoming dementia friendly' symbol * Required

16. Please confirm that your community intends to (1) Work towards the foundation criteria (2) Provide a short update on progress and next steps at 6 months (3) Complete an annual self-assessment required before the anniversary of your registration (4) Commit to the terms and conditions of use for the 'working to become dementia friendly symbol' * Required